Shots fired: evaluation of vascular injury, compartment syndrome, and transfusion rates among civilian ballistic orthopaedic fracture patients presenting to two Level I trauma centres.

PURPOSE: This study investigates baseline patient demographics and predictors of vascular injury, blood transfusion, and compartment syndrome in patients with orthopaedic fractures secondary to GSWs at two high-volume Level I trauma centres. METHODS: A retrospective chart review of all GSW-related trauma patients at two Level I trauma centres between July 2019 and September 2021 was conducted. Chi-squared and two-tailed independent t tests were used for data analysis, and logistic regression with odds ratios (OR) determined predictors of primary outcomes. RESULTS: Among 478 GSW patients, 94 (19.7%) sustained 130 orthopaedic fractures, most commonly at the lower extremity (77.7%). Orthopaedic fracture patients showed significantly higher rates of vascular injury (29.8 vs. 4.7%, p < 0.001), transfusion (27.7 vs. 12.8%, p = 0.006), and compartment syndrome (3.2 vs. 0.3%, p = 0.011) compared to non-orthopaedic injury patients. Univariable analysis identified ankle (OR = 47.50, p < 0.001) and hip/femur fractures (OR = 5.31, p < 0.001) as predictors of vascular injury. Multivariable logistic regression revealed lower extremity vascular injury (OR = 54.69, p = 0.006) and anatomic fracture sites of the humerus (OR = 15.17, p = 0.008), clavicle/scapula (OR = 11.30, p = 0.009), and acetabulum/pelvis (OR = 7.17, p = 0.025) as predictors of blood transfusion. Univariable analysis showed lower extremity vascular injury (OR = 30.14, p = 0.007) as a predictor of compartment syndrome. CONCLUSION: These findings underscore the importance of diagnosing and managing vascular injuries and compartment syndrome in GSW-related orthopaedic fractures, emphasizing the necessity for targeted transfusion strategies in such cases.

Predictors of 30-day mortality, unplanned related readmission and reoperation among isolated closed femoral shaft fractures.

Background: Isolated, closed, femoral shaft fractures are dangerous injuries that commonly occur in the setting of high energy trauma or among older patients with significant comorbidities. Despite their prevalence, relatively little data exists connecting patient independent risk factors to the time to 30-day mortality, unplanned reoperations and unplanned readmissions in these fractures. Methods: Using National Surgical Quality Improvement Program (NSQIP) database, isolated close femoral shaft fractures were identified using ICD-10 codes. Patient demographics, perioperative course and adverse events were identified. Categorical and binary variables were analyzed among procedure cohorts using Chi2 analysis. Univariate and multivariate analysis were conducted to identify independent risk factors associated with primary outcomes. Results: Between 2010 and 2019, 1346 closed isolated femoral shaft fracture patients with a mean age of 66.7 were identified, of whom 30.6% and 69.4% were male and female, respectively. Surgical procedures included: 915 (68.0%) intramedullary nail (IMN); 428 (31.8%) open reduction internal fixation (ORIF); and 3 (0.2%) external fixator (Ex-fix). Patients who underwent ORIF reported 3.19 (OR: 3.19; CI: 1.45-7.03; p = 0.004) and 2.12 (OR: 2.12; CI: 1.10-4.09; p = 0.024) increased odds of mortality and unplanned related readmission compared to patients who received IMN. Transfusion, DVT, and PE rates were 34.2%, 1.4%, and 1.1%, respectively. Furthermore, 50% of mortality cases occurred within 6 days of surgery. Patients requiring reintubation reported 61.8 (OR: 61.8; CI: 15.7-242.40; p < 0.001) increased odds of mortality compared to patients not requiring reintubation. Conclusion: Patients with femoral shaft fractures who require reintubation have increased odds of mortality than those successfully extubated. In addition to precautions prior to extubation, patients with femoral shaft fractures should also be carefully monitored for the development of DVT or PE, and they should be definitively fixed with IMN whenever possible.

Use of Direct Oral Anticoagulants Among Patients With Hip Fracture Is Not an Indication to Delay Surgical Intervention.

OBJECTIVES: To compare outcomes in patients on direct oral anticoagulants (DOACs) treated within 48 hours of last preoperative dose with those with surgical delays >48 hours. DESIGN: Retrospective cohort study. SETTING: Three academic Level 1 trauma centers. PATIENT SELECTION CRITERIA: Patients 65 years of age or older on DOACs before hip fracture treated between 2010 and 2018. Patients were excluded if last DOAC dose was >24 hours before admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC. OUTCOME MEASURES AND COMPARISONS: Primary outcome measures were the postoperative complication rate as determined by diagnosis of deep venous thrombosis or pulmonary embolus, wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality. RESULTS: Two hundred five patients were included in this study, with a mean cohort age of 81.9 years (65-100 years), 64% were (132/205) female, and a mean Charlson Comorbidity Index of 6.4 (2-20). No significant difference was observed among age, sex, Charlson Comorbidity Index, or fracture pattern between cohorts (P > 0.05 for all comparisons). Seventy-one patients had surgery <48 hours after final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the 2 cohorts was observed (P = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI, 1.05-5.44; P = 0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 vs. 7.6 days, P < 0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (P > 0.05 for all comparisons). CONCLUSIONS: Geriatric patients with hip fracture who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates with patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Optimizing Outcomes after Operative Treatment Bicondylar Tibial Plateau Fractures - Time for Innovation?

Bicondylar tibial plateau fractures are technically demanding fractures that have a high complication rate. We sought to review the recent literature with the aim to summarize the development of new classification systems that may enhance the surgeon's understanding of the fracture pattern and injury. We highlight the best methods for infection control and touch on new innovative solutions using 3D printer models and augmented mixed reality to provide potentially personalized solutions for each specific fracture configuration.

Metabolic Syndrome Increases Risk of Readmission and Complications in Operative Fixation of Pilon Fractures.

Background Studies demonstrate that metabolic syndrome (MetS) negatively impacts surgical outcomes. This study sought to identify how metabolic syndrome affects outcomes after open reduction and internal fixation (ORIF) of traumatic pilon fractures. Methods Patients who underwent ORIF for pilon fractures from 2012 to 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients with MetS were compared to non-MetS patients for rates of adverse events, prolonged stay, readmission, discharge location, and operative time in the 30-day postoperative period. All statistical analyses were conducted using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Paired student t-tests were used to assess continuous variables. Pearson's Chi-square and odds ratios were used for categorical variables. Results A total of 1,915 patients met this study's inclusion criteria, and 127 MetS patients were identified in the cohort. The MetS cohort was older (62.7 vs 49.5 years old, p-value <0.01), with a greater proportion of female patients (59.1% vs 50.2%, p=0.054). MetS patients experienced significantly higher rates of infectious complications (7.9% vs 3.9% OR 2.75 (CI 1.36-5.53), p=0.008), major adverse events (11% vs 4.3%, OR 2.79 (CI 1.53-5.09) p=0.002), and readmissions. MetS patients also had longer lengths of stay (7 days vs 3.8 days, p-value<0.001), and were more likely to be discharged to a non-home location (51.2% vs 19.5%, p-value<0.01, OR 4.32 (CI=3.0-6.24) p<0.001). Conclusion Patients with MetS have an increased risk of 30-day major complications, infection, readmissions, discharge to a non-home location, and prolonged operative time, and therefore warrant additional consideration for perioperative monitoring.

Trends in non-operative management of low-energy pelvic fracture: An analysis of the Nationwide Inpatient Sample.

Introduction: Non-operative management is common for low-impact pelvic fractures. In this study, we characterize the epidemiology of those treated nonoperatively following low-energy pelvic fracture, while identifying recent management trends. Methodology: Data from the Nationwide Inpatient Sample (NIS) database from 2011 to 2018 were analyzed. We identified adult patients diagnosed with pelvic fracture based on International Classification of Diseases (ICD) codes, excluding fractures of the acetabulum, femur, polytrauma, and open fractures to isolate cases caused by low-impact mechanisms. Codes indicating operative management were excluded. Demographic information and outcomes (length of stay, in-hospital mortality, hospital discharge status) were collected. Sub-analyses were performed to identify trends. Findings: 123,936 eligible patients were identified. The average age was 68.7 years. 70% were female, showing a decline from 75% to 66% over the study period. Pubic bone involvement was observed in 59% of fractures. The mean Charlson Comorbidity Index (CCI) was 3.83, corresponding to a 10-year survival rate of 58.5%, which remained relatively stable throughout the study period. 62.4% of patients received treatment at urban teaching hospitals. Average length of hospital stay was 6.3 days. Discharge to a skilled nursing facility (SNF) was the most common outcome, ranging from 62.1% to 65.0% during the study period, while 20.0% of patients were discharged home (18.4%-21.1%). Mean in-hospital mortality was 3.28%, showing no significant change, with higher rates among male patients (5.1%) and patients of Asian descent (3.8%). Conclusion: The majority of patients receiving nonoperative treatment for low-energy pelvic fractures were females in their mid-60s with moderate comorbidity. The study reveals a relatively high in-hospital mortality rate of 3.28%, particularly among male patients and those of Asian descent, indicating the need for increased surveillance for further injury in these groups. Most patients were discharged to a SNF, highlighting the necessity for extended rehabilitation in this population. This persistent trend is noteworthy considering the growing emphasis on the cost of inpatient admissions and advancements in outpatient management of orthopedic injuries.

Operative and Nonoperative Treatment of Humeral Shaft Fractures: A Cost-Effectiveness Analysis.

BACKGROUND: Decision-making with regard to the treatment of humeral shaft fractures remains under debate. The cost-effectiveness of these treatment options has yet to be established. This study aims to compare the cost-effectiveness of operative treatment with that of nonoperative treatment of humeral shaft fractures. METHODS: We developed a decision tree for treatment options. Surgical costs included the ambulatory surgical fee, physician fee, anesthesia fee, and, in the sensitivity analysis, lost wages during recovery. We used the Current Procedural Terminology codes from the American Board of Orthopaedic Surgery to determine physician fees via the U.S. Centers for Medicare & Medicaid Services database. The anesthesia fee was obtained from the national conversion factor and mean operative time for included procedures. We obtained data on mean wages from the U.S. Bureau of Labor and data on weeks missed from a similar study. We reported functional data via the Disabilities of the Arm, Shoulder and Hand (DASH) scores obtained from existing literature. We used rollback analysis and Monte Carlo simulation to determine the cost-effectiveness of each treatment option, presented in dollars per meaningful change in DASH score, utilizing a $50,000 willingness-to-pay (WTP) threshold. RESULTS: The cost per meaningful change in DASH score for operative treatment was $18,857.97 at the 6-month follow-up and $25,756.36 at the 1-year follow-up, by Monte Carlo simulation. Wage loss-inclusive models revealed values that fall even farther below the WTP threshold, making operative management the more cost-effective treatment option compared with nonoperative treatment in both settings. With an upward variation of the nonoperative union rate to 84.17% in the wage-exclusive model and 89.43% in the wage-inclusive model, nonoperative treatment instead became more cost-effective. CONCLUSIONS: Operative management was cost-effective at both 6 months and 1 year, compared with nonoperative treatment, in both models. Operative treatment was found to be even more cost-effective with loss of wages considered, suggesting that an earlier return to baseline function and, thus, return to work are important considerations in making operative treatment the more cost-effective option. LEVEL OF EVIDENCE: Economic and Decision Analysis Level III . See Instructions for Authors for a complete description of levels of evidence.

E-scooter use continues to rev up fracture diagnoses and hospital admissions compared to other modes of transportation.

Introduction: The COVID-19 pandemic was associated with an increase in popularity of e-scooter usage and a rise in e-scooter related injuries. Recent studies have elucidated trends within e-scooter injuries but there are few epidemiological studies that evaluate injury rates amongst multiple modes of transportation. This study seeks to investigate trends of e-scooter orthopedic fracture injuries compared to other traditional methods of transportation using a national database. Methods: The National Electronic Injury Surveillance System (NEISS) database was queried between 2014 and 2020 for patients who were injured after usage of e-scooters, bicycles, or all-terrain vehicles. Primary analysis included patients with a diagnosis of fracture and utilized univariate/multivariate models to evaluate risk of hospital admission. Secondary analysis included all isolated patients to evaluate the odds of fracture development amongst modes of transportation. Results: A total of 70,719 patients with injuries associated with e-scooter, bicycle, or all-terrain vehicle use were isolated. 15997 (22.6%) of these patients had a fracture diagnosis. Both e-scooters and all-terrain vehicles reported increased odds of fracture-related injury and direct hospitalization when compared to bicycles. E-scooter users reported a greater odds of both associated fracture (OR 1.25; 95%CI 1.03-1.51; p = 0.024) and hospital admission (OR: 2.01; 95%CI: 1.26-3.21; p = 0.003) in 2020 compared to 2014-2015. Discussion: E-scooter related orthopedic injuries and hospital admissions had the largest incidence rate increase compared to bicycle and all-terrain vehicles between 2014 and 2020. E-scooter fractures were most commonly located in the lower leg in 2014-2017, the wrist in 2018-2019, and the upper trunk in 2020. In comparison, bicycle and all-terrain vehicle fractures was most commonly shoulder and upper trunk within the study period. Further research will help to promote further understanding of the e-scooter health care burden and in prevention of these injuries. Level of evidence: 3.

Is There a Role for Anti-factor Xa Activity Assay in Venous Thromboembolism Prophylaxis Management Among Orthopaedic Trauma Patients? Systematic Review and Meta-analysis.

OBJECTIVES: To determine the effect of anti-factor Xa assay dosing of low-molecular-weight heparin (LMWH) on rates of venous thromboembolism (VTE), deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, and mortality among orthopaedic trauma patients. DATA SOURCES: PubMed/MEDLINE, Embase, Ovid, Cochrane Central Register of Controlled Trials (CENTRAL), clinicaltrials.gov , and Scopus were systematically searched from inception of the database to 2021. STUDY SELECTION: Prospective, retrospective, and randomized controlled trial studies were included if they compared rates of VTE, DVT, PE, bleeding, and/or mortality between orthopaedic trauma patients receiving anti-factor Xa-based LMWH dosing and those receiving standard dosing. DATA EXTRACTION: Two independent reviewers screened titles and abstracts for eligibility. Study characteristics including study design, inclusion criteria, and intervention were extracted. DATA SYNTHESIS: Meta-analysis was performed using pooled proportion of events (effect size) with 95% confidence intervals. A random-effects model was used. Heterogeneity was quantified by Higgins I 2 . Heterogeneity and variability between subgroups indicated differences in the pooled estimate represented by a P -value. RESULTS: Six hundred eighty-five studies were identified, and 10 studies including 2870 patients were included. In total, 30.3% and 69.7% received an adjusted and nonadjusted dose of LMWH, respectively. The rate of VTE and DVT were significantly lower in the anti-factor Xa-adjusted cohort, whereas there was no statistically significant difference in rates of PE, bleeding, or mortality between the cohorts. CONCLUSIONS: This systematic review and meta-analysis demonstrates that anti-factor Xa activity assay dosing of LMWH among orthopaedic trauma patients leads to a reduction in overall DVT rates, although not PE rates, without an increased risk of bleeding events. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of associated both-column acetabular fractures with and without a posterior wall fracture- A retrospective observational cohort study.

Aims & objectives: Our study sought to determine if posterior wall (PW) involvement in associated both-column acetabular fractures (ABCAFs) is associated with different clinical outcomes, primarily rate of conversion to total hip arthroplasty (THA), in comparison to ABCAFs with no PW involvement. Materials & methods: This retrospective observational cohort study was performed at two academic Level 1 trauma centers. Two study groups were identified. The first study group consisted of 18 patients who sustained an ABCAF with PW involvement (+PW). The second study group consisted of 26 patients who sustained an ABCAF with no PW involvement (-PW). All patients achieved a minimum 12-months of follow-up and/or received a THA conversion procedure at a time remote to their index open reduction internal fixation (ORIF) procedure. The primary outcome of this study was subsequent conversion to THA on the injured hip. The secondary outcome was the presence of post-operative pain at ≥6 months and/or complications. Results: No difference in rate of conversion to THA between + PW (n = 4, 22.2%) and -PW (n = 3, 11.5%) groups was demonstrated (p = 0.419). Similarly, no differences were seen between groups regarding complication rate (p = 0.814) and post-operative pain (p = 0.142). Conclusion: Involvement of the PW does not appear to create worse clinical outcomes in comparison to no involvement in ABCAFs particularly as it relates to ipsilateral joint replacement.

Impact of Age on Functional Outcome After Reverse Shoulder Arthroplasty Performed for Proximal Humerus Fractures or Their Sequelae.

Background: The use of reverse shoulder arthroplasty (RSA) to treat displaced, unstable 3- and 4-part proximal humerus fractures (PHFs) has traditionally been reserved for patients over 70 years old. However, recent data suggest that nearly one-third of all patients treated with RSA for PHF are between 55-69 years old. The purpose of this study was to compare outcomes for patients younger than 70 versus patients older than 70 years of age treated with RSA for a PHF or fracture sequelae. Methods: All patients who underwent primary RSA for acute PHF or fracture sequelae (nonunion, malunion) between 2004 and 2016 were identified. A retrospective cohort study was performed comparing outcomes for patients younger than 70 versus older than 70. Bivariate and survival analyses were performed to evaluate for survival complications, functional outcomes, and implant survival differences. Results: A total of 115 patients were identified, including 39 patients in the young group and 76 cases in the older group. In addition, 40 patients (43.5%) returned functional outcomes surveys at an average of 5.51 years (average age range: 3.04-11.0 years). There were no significant differences in complications, reoperation, implant survival, range of motion, DASH (27.9 vs 23.8, P=0.46), PROMIS (43.3 vs 43.6, P=0.93), or EQ5D (0.75 vs 0.80, P=0.36) scores between the two age cohorts. Conclusion: At a minimum of 3 years after RSA for a complex PHF or fracture sequelae, we found no significant difference in complications, reoperation rates, or functional outcomes between younger patients with an average age of 64 years and older patients with an average age of 78 years. To our knowledge, this is the first study to specifically examine the impact of age on outcome after RSA for the treatment of a proximal humerus fracture. These findings indicate that functional outcomes are acceptable to patients younger than 70 in the short term, but more studies are needed. Patients should be counseled that the long-term durability of RSA performed for fractures in young, active patients remains unknown.

Severe Obesity Worsens 30-Day Surgical Outcomes and Projected Costs in Operative Femoral Shaft and Tibial Shaft Fractures.

OBJECTIVE: To assess the impact of severe obesity on 30-day adverse event rates, hospital length of stay (LOS), readmissions, and projected costs after operative fixation of tibia and femur fractures. METHODS: An analysis of the American College of Surgeons National Surgical Quality Improvement Project database from 2012 to 2019 of isolated femoral shaft and tibial shaft fracture fixation cases was conducted. Adverse events, LOS, readmission rates, and operative time were queried for severe obesity, defined as body mass index greater than 40, compared with other patients. Student t tests were used to assess continuous variables. Fisher exact test and odds ratios were used for categorical variables. A cost-analysis was also performed to quantify the effect of severe obesity on projected health care expenditures. RESULTS: A total of 10,436 patients were included with 7.0% of patients categorized as severely obese. Severely obese patients had higher infectious complication rates (9.0% vs. 6.7%, P = 0.013, OR 1.36, 95% CI 1.04-1.78), readmission rates (7.9% vs. 5.6%, P-value = 0.008, OR 1.44, 95% CI 1.08-1.91), longer LOS (5.8 days SD ±10.2 vs. 5.0 days SD ±7.9 days, P-value = 0.008), and longer operative times (mean 115 minutes ± 56 minutes SD vs. 103 minutes SD ±54 minutes, P-value = <0.001). Severe obesity resulted in an estimated $4258.07 additional health care expenditures per patient compared with nonobese patients. This amounted to a projected added total expenditure of $3.09 million USD in the overall cohort. CONCLUSION: Severe obesity is associated with significantly worse 30-day outcomes and higher readmission rates for patients undergoing operative fixation of tibial shaft and femoral shaft fractures. Health policy considerations should be made to incentivize care for this patient population, particularly in trauma where modification of risk factors before surgery is often not feasible. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A review of open pelvic fractures with concurrent genitourinary injuries.

INTRODUCTION: Open pelvic fractures (OPFs) are uncommon but potentially lethal traumatic injuries. Often caused by high energy blunt trauma, they can cause severe injury to abdominal and pelvic structures. We sought to conduct a review of the literature in order to ascertain the rates of genitourinary injury and vaginal laceration after OPF and the rates of resulting infection and mortality. METHODS: A review of PubMed was conducted to identify studies reporting the rates of genitourinary injury from OPF. Study characteristics, patient characteristics, and outcomes were collected. The data were pooled, and descriptive statistics were obtained. RESULTS: Eight studies encompassing 343 patients were included. Average age was 35.1 years (10-85.9), 28% were female, and the average Injury Severity Score was 26.5 (4-75). 95.5% of patients had a blunt mechanism of injury. Motor vehicle collision (23.9%), motorcycle accident (19.7%), and pedestrian struck (19.3%) were the most common etiologies. Overall mortality and infection rates were 31.2% and 18.7%, respectively. 19.7% of patients suffered an injury to the genitourinary system, and 32.4% of females sustained a vaginal laceration. DISCUSSION: OPFs have the potential for extremely high morbidity and mortality. While much research has been done to prevent early mortality from hemorrhage, there is comparatively little research into late mortality stemming from infection and sepsis. Intravenous antibiotics are the mainstay of treatment, and local antibiotics usage has been encouraged. In patients with a vaginal laceration, it is important to provide antibiotic coverage for vaginal flora.

Efficacy of Accessory Facet Views in the Detection of Occult Patellar Malreduction: A Biomechanical Analysis.

A simulated fracture model was used to determine the ability of the medial and lateral patellar facet views in detecting magnitudes of articular displacement. Transverse patellar fractures were simulated in ten patients. Medial and lateral translation of the distal fragment were evaluated in 1 mm increments and rotational malalignment along the longitudinal axis of the patella was evaluated in 5 mm increments. In comparison to the true lateral view, the utilization of the medial and lateral patellar facet views considerably improves detection of occult articular surface malreduction.

Surgical demographics of acute thigh compartment syndrome.

BACKGROUND: The objective of this study was to identify demographic, injury-related, and treatment-related characteristics of patients who underwent decompressive fasciotomies for acute thigh compartment syndrome. METHODS: A cohort of 38 adult patients with acute thigh compartment syndrome treated with fasciotomy at two tertiary care referral centers over a 10-year time period from January 1, 2006 to June 30, 2015 were retrospectively identified. We searched the electronic medical record for patient-related variables (e.g., age, sex, race, smoking status, diabetes mellitus), injury-related variables (e.g., mechanism of injury, associated fractures, other traumatic injuries), treatment-related variables (e.g., delay to treatment, compartments released, number of debridements, use of split-thickness grafts), and outcomes (e.g., amputation, death, sensory/motor impairments at final follow-up). RESULTS: The mean age of our cohort was 47 years, and 35 patients (92%) were male. There were various mechanisms of injury, but the most common mechanisms were spontaneous hematoma (21%), followed by motor vehicle accidents (16%). Associated leg fractures were present in 15 (39%) patients. Delay between time of injury and fasciotomy was greater than 24 hours in 27 patients (71%), 12 to 24 hours in 6 patients (16%), and less than 6 hours in 3 patients (8%). The most frequently released compartment was the anterior compartment only (68%), followed by both the anterior and posterior compartments (16%) and the posterior compartment only (11%). Six patients (16%) had motor impairment, and 2 patients (5%) had sensory impairment at final follow-up. There were 2 deaths (5%) recorded in the hospital course for this cohort, none of which were directly related to compartment syndrome of the thigh. CONCLUSION: Delays to fasciotomy are frequent in the treatment of acute thigh compartment syndrome. The demographics of acute thigh compartment syndrome demonstrate a strong male predominance. Treating providers should recognize spontaneous hematoma and motor vehicle accidents as the most common causes of acute thigh compartment syndrome.

Can Partially Threaded Cannulated Screws Be Better Designed to Maximize Purchase in the Sacrum?

Sacroiliac screw fixation involves the use of cannulated, partially or fully threaded screws. Current partially threaded screws have standardized thread lengths involving a small portion of the screw regardless of its overall length. Forty uninjured computed tomography images were evaluated for distances from the lateral iliac cortex to the lateral sacral cortex at the first and second sacral segments. No difference in measurements were observed for gender, age, or body mass index. Using a smooth segment value of 32 mm, a significant increase in thread lengths is achievable allowing for a novel sacroiliac screw design to achieve greater purchase in the sacrum.

Comparison of Risk Factors and Postoperative Outcomes in Syndesmosis Injuries with Various Ankle Fracture Types.

There is a lack of understanding of risk factors and postoperative outcomes of syndesmotic injuries with singular versus multipart fractures. A retrospective analysis was done between 2008 and 2016, utilizing the American College of Surgeons National Surgical Improvement Program database. Patients with open reduction and internal fixation of isolated lateral malleolus fractures, bimalleolar fractures, or trimalleolar fractures were identified. A total of 2045 patients underwent syndesmotic fixation. Subjects with bimalleolar or trimalleolar fractures were more likely than those with unimalleolar fractures to be Caucasian (odds ratio [OR] = 1.5 and 1.9), female (OR = 1.8 and 2.9), aged > 65 years (OR = 1.6 and 1.9), or have American Society of Anesthesiologists (ASA) classification III (OR =1.5 and 1.4) (all, P ≤ 0.028). Patients with a unimalleolar fracture were more likely than those with a bimalleolar or trimalleolar fracture to be male (OR = 1.8 and 2.9), African American (OR = 1.5 and 1.8), aged < 30 years (OR = 1.4 and 1.8), or present with an ASA I classification (OR = 1.6 and 2.0) (all, P ≤ 0.004). Subjects with bimalleolar or trimalleolar fractures were more likely than those with unimalleolar fractures to have lengthier hospital stays (OR = 1.8 and 2.1), while patients with trimalleolar fractures were more likely than those with unimalleolar fractures to have hypoalbuminemia (OR = 2.3), develop a complication (OR = 2.2) or an open wound (OR = 1.9), or to be readmitted (OR = 2.2) (all, P ≤ 0.036). In this study, comorbidity rates and adverse postoperative outcomes significantly increased as the number-part fractures increased in syndesmotic fixation patients. Risk factors also varied across fracture severity.

A Systematic Review of the Management of Upper Extremity Orthopaedic Injuries in Epileptic Patients.

Background: During seizures, injury of the upper extremities may occur. Standardized guidelines are deficient for diagnosis and perioperative care. Methods: PubMed, Embase, Cochrane, Scopus, and Web of Science databases were systematically screened using predefined search terms. Results: Of the 59 patients included, 36 (61.0%) involved a posterior shoulder dislocation. Associated fractures were observed in 34 (57.6%) cases with surgical procedures performed in 30 (50.8%) patients. Functional outcomes were reported in 44 patients, with over half (23 of 44, [52.2%]) endorsing range of motion deficits. Conclusion: Standardized guidelines, to guarantee timely management of injury in post-seizure patients, are needed with a customized treatment approach that accommodates the various aspects of their condition.

Epidemiology of Fragility Pubic Ramus Fractures in the United States.

Introduction: Previous studies illustrate significant increases in pelvic fracture incidence; however, there is a paucity of information on the incidence of osteoporotic pelvic ring injuries based on large-scale examinations of geographically and ethnically diverse populations. This study addresses the epidemiology of osteoporotic pubic ramus fractures in the United States and details differences in incidence rates with respect to age, gender, and race. Materials and Methods: National Electronic Injury Surveillance System (NEISS) data between 2002 and 2019 was gathered for individuals aged 60 and above presenting to U.S. emergency departments with ramus fractures. Incidence rates for ramus injuries were calculated using adjusted U.S. Census Bureau estimates of population. Fracture incidences were calculated for age, gender, and race strata. Results: The overall incidence rate of pubic ramus fractures in the United States between 2002 and 2019 was 13.47 per 1,000,000 people 60 years and older (95% confidence limit: 9.92-17.01). The incidence of pubic ramus fractures for females in the US was 21.71 (16.08-27.34). Rates of ramus fracture increased overall (P < .001) and for both genders between the ages of 60 and 100, though the rate increase was significantly greater in females than in males (P < .001). In terms of race, incidence was highest Asian females and lowest in Native American and Pacific Islander men. Discussion/Conclusion: : As the first national study addressing the epidemiology of ramus injuries in the United States, this work reveals these injuries comprise a significant fracture risk in the elderly. In addition, it highlights gender and ethnic strata that are more susceptible to these injuries.

Outcomes after ORIF of Bicondylar Schatzker VI (AO type C) Tibial Plateau Fractures in an Elderly Population.

BACKGROUND: The surgical management of bicondylar tibial plateau (BTP) fractures in elderly patients aims to restore knee stability while minimizing soft tissue complications. The purpose of this study was to compare injury characteristics and surgical outcomes after ORIF of BTP fractures (AO/OTA 41-C (Schatzker VI)) in young (< 50 years) versus elderly (> 65 years) patients. METHODS: A retrospective cohort study was conducted using data from two American College of Surgeons (ACS) level I trauma centers. Inclusion criteria were: (1) age 18 years or older, (2) bicondylar tibial plateau fracture (AO/OTA 41-C or Schatzker VI), (3) treatment with ORIF, and (4) minimum of 6 months follow-up. Patients between 50 and 65 years of age were excluded. Data collection was performed by reviewing electronic medical records, operative reports, and radiology reports. RESULTS: We identified 323 patients (61% male) with 327 BTP fractures and a median follow-up of 685 days. There were 230 young patients (71%) < 50 years and 93 elderly patients (29%) >6 5 years at time of presentation. Elderly patients were significantly more likely to have a low energy mechanism of injury (44.6 vs. 16.2%, p < 0.001), and present with diabetes (19.4 vs. 4.4%, p < 0.001) or coronary artery disease (12.9 vs. 1.3%, p < 0.001). Elderly patients were also significantly less likely to undergo staged management with initial knee-spanning external fixation followed by delayed ORIF (19.2 vs. 33.9%, p = 0.008). Elderly patients had a lower arc of motion at final follow-up (105 vs. 113°, p < 0.001) and reduced PROMIS-10 function scores (43.8 vs. 49.8, p = 0.013). No differences were observed in rates of superficial infection, deep infection, reoperation, or EQ-5D scores between age groups. CONCLUSIONS: This is the largest study to compare injury characteristics and outcomes after ORIF of BTP fractures according to age. Elderly patients (age > 65 years) sustained BTP fractures by lower energy mechanisms than their younger counterparts with similar fracture patterns and were often managed with ORIF. The results of this study suggest that ORIF of BTP fractures in elderly patients is associated with similar complication rates and outcomes as in younger patients despite higher comorbidities and poorer bone quality in the elderly population.